The Roots of Insomnia

One of the most common clinical presentations is insomnia. Next to digestive disorders, sleep disorders are one of the most common complaints the clinician will encounter in daily practice.

Despite its common occurrence, I am consistently perplexed at TCM practitioners who opt to use generic herbal "sleep formulas" in lieu of appropriately prescribed TCM medicinals/formulas based upon TCM pattern differentiation. I often wonder why this occurs. Why would a practitioner with years of training resort to using generic herbal formulas over TCM pattern differentiation?

I don't think there is a standardized generic answer for this question. Perhaps the generic herbal formulas are effective or perhaps the practitioners are overwhelmed or lazy with diagnostic skills. As an herbalist trained in TCM, Ayurvedic and Western herbalism, I rarely resort to "generic" herbal sleep formulas in daily clinical practice. Let's explore some important ideas for treating insomnia integrating TCM medicinals into varied herbal protocols in order to address the root and the branch of the presenting sleep disturbance.

The most important idea to address when treating insomnia in an integrative fashion utilizing TCM pattern differentiation in conjunction with over-the-counter herbal remedies in the basic foundational idea of treating both the root and the branch of any symptom presentation. Sleep disturbances are, in most cases, complex issues and are not simply due to stress, hence the importance of the use of TCM pattern differentiation. Within the clinical presentation of insomnia, numerous TCM patterns can be expressed: blood vacuity, yin vacuity, qi vacuity, heart fire, liver fire, phlegm heat and yin vacuity heat to name just a few. When one considers this basic list of TCM patterns and the potential interaction and cross-pollination of two to three patterns overlapping at the same time, it quickly becomes apparent that the simple use of the shotgun approach of generic herbal "sleep formulas" can be a poor choice if the clinician wishes to adequately resolve the patient's unique sleep disturbance.

This is the overarching idea in this short article: TCM practitioners should not simply hand out calming/sedative herbs in a blind attempt to ameliorate a patient's sleep disturbance. This short article is not an attempt to exhaustively discuss each and every TCM pattern presentation in cases of insomnia; this subject can easily be found in various excellent TCM reference texts. What I do hope to accomplish is to inspire TCM practitioners to realize that the foundational idea of treating the root and the branch is a key idea when dealing with sleep disturbances in the modern clinic.

The most common herbs which I see TCM practitioners resort to using in cases of insomnia, in lieu of TCM pattern differentiation is as follows: Valerian root, Passionflower, Chamomile, Hops, Skullcap, California Poppy, Lavender, and Kava. It is also quite common to find any or all of the aforementioned herbal sedatives combined together in formulas; and this also is frequently combined with the supplement Melatonin as well. This is what I refer to as a "shotgun" approach: combining a group of sedative herbs together in an attempt to "knock the patient out." While this can help some patients, for TCM practitioners to resort to this simplistic approach in lieu of using professional TCM pattern differentiation is frankly unprofessional. The aforementioned herbs are wonderful herbs, I use these medicinals almost daily in my practice; however I do not ignore TCM pattern differentiation. If a TCM practitioner uses generic western sedative herbs for insomnia, they should also use standard TCM diagnostic protocol in order to treat the root and the branch.

The most common patterns I personally see in cases of insomnia is liver depression qi stagnation, depressive heat, heart/liver blood vacuity, and kidney yin vacuity. Each of these TCM pattern differentiations expresses complex ideas which are far beyond simply issues of hyperactive nervous systems in need of basic sedatives. Therefore, the use of herbs such as valerian, chamomile and hops will not adequately target these more deeply rooted disease presentations. There is nothing inherently wrong with a TCM practitioner using sedative herbs in cases of insomnia. However, ignoring basic TCM diagnostics is problematic. The following is a basic example of how practitioners can integrate basic herbal sedatives with appropriate TCM herbal formulas with the most common TCM patterns I see in clinical presentations of insomnia.

Liver Depression Qi Stagntion

Xiao Yao Wan in combination with basic herbal sedative is an excellent way effective treat the root and the branch in clinical presentations of insomnia. I commonly use Kava and Chamomile with Xiao Yao Wan when insomnia cases express standard symptoms of liver depression qi stagnation. In cases of depressive heat, I use Jia Wei Xiao Yao Wan with basic western sedative herbs with excellent results, as well effectively treating the root and the branch of sleep issues.

Heart/Liver Blood Vacuity

These cases are particularly important to use TCM medicinals as basic herbal sedatives do not supplement blood and can easily mask the deeper issues of blood vacuity. When the practitioner ignores blood vacuity and just makes the patient "tired," deeper issues of liver and kidney vacuity can develop resulting in recalcitrant cases of insomnia and other deeper issues.

Kidney Yin Vacuity/Vacuity Heat

This is perhaps the most obvious TCM pattern differentiation in which basic herbal sedatives will not work. These are the most common pattern presentations with patients who are not responding to prescribed sleep medications and basic herbal sedative formulas. Depending upon the severity of the vacuity heat, this pattern can be harder and more complex to effectively resolve. These cases require the use of lifestyle changes and education on appropriate sleep habits/sleep hygiene in combination with appropriate prescribed TCM formulas to target yin vacuity and or vacuity heat.

There are numerous other possible syndromes in insomnia, however these are the three most common I see in clinical practice. Simply giving a patient Melatonin, kava, or valerian root will not address the underlying root syndromes. It is the ethical and medical responsibility of the practitioner to keep this in mind when managing sleep disturbances and to consider both the root and the branch in such issues. It will be quite common to add TCM medicinals such as Suan Zao Ren or He Huan Pi to formulas to help patients sleep, therefore there is nothing wrong with using melatonin, kava or valerian root in conjunction with TCM formulas. This is actually the ideal approach for case management in such cases. The practitioner can educate the patient on the importance of treating both the root and the branch of a respective malady and this can also serves as an effective way for the practitioner and patient to form a healthy and long-term relationship whereby the practitioner assumes the role of teacher as well as "physician." The practitioner can discuss lifestyle and dietary changes to address root issues and use TCM pattern differentiation to target the reasons why a sleep disturbance has arisen, and use appropriate sedative herbs in conjunction with TCM formulas in a seamless integrative fashion. When the protocols are designed in this manner, it allows seeds of change to be planted which when nourished, can sprout into long-term health and symptom resolution for the patient. Tend to the roots and the branches can thrive!

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